Basic Information
| Provider Information | |||||||||
| NPI: | 1790756187 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOE | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | CHESTER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2730 PROSPERITY AVE STE B | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032891400 | ||||||||
| FaxNumber: | 7032891414 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 GALLOWS ROAD | ||||||||
| Address2: | INOVA CHILDREN'S HOSPITAL | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220421210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032891400 | ||||||||
| FaxNumber: | 7032891414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 05/24/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 0101057905 | VA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
No ID Information.